Large-scale delivery of seasonal malaria chemoprevention to children under 10 in Senegal: an economic analysis.

Seasonal Malaria Chemoprevention (SMC) is recommended for children under 5 in the Sahel and sub-Sahel. The burden in older children may justify extending the age range, as has been done effectively in Senegal. We examine costs of door-to-door SMC delivery to children up to 10 years by community health workers (CHWs). We analysed incremental financial and economic costs at district level and below from a health service perspective. We examined project accounts and prospectively collected data from 405 CHWs, 46 health posts, and 4 district headquarters by introducing questionnaires in advance and completing them after each monthly implementation round. Affordability was explored by comparing financial costs of SMC to relevant existing health expenditure levels. Costs were disaggregated by administration month and by health service level. We used linear regression models to identify factors associated with cost variation between health posts. The financial cost to administer SMC to 180 000 children over one malaria season, reaching ∼93% of children with all three intended courses of SMC was $234 549 (constant 2010 USD) or $0.50 per monthly course administered. Excluding research-participation incentives, the financial cost was $0.32 per resident (all ages) in the catchment area, which is 1.2% of Senegal's general government expenditure on health per capita. Economic costs were 18.7% higher than financial costs at $278 922 or $0.59 per course administered and varied widely between health posts, from $0.38 to $2.74 per course administered. Substantial economies of scale across health posts were found, with the smallest health posts incurring highest average costs per monthly course administered. SMC for children up to 10 is likely to be affordable, particularly where it averts substantial curative care costs. Estimates of likely costs and cost-effectiveness of SMC in other contexts must account for variation in average costs across delivery months and health posts.

Costs and cost-effectiveness of delivering intermittent preventive treatment through schools in western Kenya.

BACKGROUND: Awareness of the potential impact of malaria among school-age children has stimulated investigation into malaria interventions that can be delivered through schools. However, little evidence is available on the costs and cost-effectiveness of intervention options. This paper evaluates the costs and cost-effectiveness of intermittent preventive treatment (IPT) as delivered by teachers in schools in western Kenya. METHODS: Information on actual drug and non-drug associated costs were collected from expenditure and salary records, government budgets and interviews with key district and national officials. Effectiveness data were derived from a cluster-randomised-controlled trial of IPT where a single dose of sulphadoxine-pyrimethamine and three daily doses of amodiaquine were provided three times in year (once termly). Both financial and economic costs were estimated from a provider perspective, and effectiveness was estimated in terms of anaemia cases averted. A sensitivity analysis was conducted to assess the impact of key assumptions on estimated cost-effectiveness. RESULTS: The delivery of IPT by teachers was estimated to cost US$ 1.88 per child treated per year, with drug and teacher training costs constituting the largest cost components. Set-up costs accounted for 13.2% of overall costs (equivalent to US$ 0.25 per child) whilst recurrent costs accounted for 86.8% (US$ 1.63 per child per year). The estimated cost per anaemia case averted was US$ 29.84 and the cost per case of Plasmodium falciparum parasitaemia averted was US$ 5.36, respectively. The cost per case of anaemia averted ranged between US$ 24.60 and 40.32 when the prices of antimalarial drugs and delivery costs were varied. Cost-effectiveness was most influenced by effectiveness of IPT and the background prevalence of anaemia. In settings where 30% and 50% of schoolchildren were anaemic, cost-effectiveness ratios were US$ 12.53 and 7.52, respectively. CONCLUSION: This study provides the first evidence that IPT administered by teachers is a cost-effective school-based malaria intervention and merits investigation in other settings.

Monitoring antimalarial drug resistance within National Malaria Control Programmes: the EANMAT experience.

The National Malaria Control Programme (NMCP), organized within the Ministry of Health (MoH), is an essential component for the planning, execution and coordination of malaria control activities. As effective case management remains the mainstay of malaria control in almost every African country, antimalarial drug resistance is a major barrier to the implementation of effective malaria control policies. In order to function effectively, these units must have an efficient surveillance system which can provide reliable and current estimates of the severity of drug resistance. Without this information, it is impossible for the MoH to design and promote a rational antimalarial policy, but because of limited resources, especially of people and expertise, most NMCPs have been unable to initiate and manage such a system. The need for collaborative partnerships between the MoH and the research community prompted the establishment of the East Africa Network for Monitoring Antimalarial Treatment (EANMAT). EANMAT has attempted to bring together the complimentary skills of malaria researchers and MoH staff in four east African countries. After 3 years of operation, data generated by EANMAT have been used to review and modify national malaria treatment policies in Kenya, Uganda, Rwanda and Tanzania. This new approach, which forges a closer working relationship between the research and policy communities, has effectively built capacity around the complex of surveillance, interpretation and use of evidence within a policy environment. The added-value of this approach is that the research community has learned to appreciate the constraints of policy development, and that the control community has established the need to build capacity and ownership of research evidence. Networks similar to EANMAT should be encouraged elsewhere in Africa to engender similar partnerships: to assist the development of rational treatment policies, and thus more effective malaria chemotherapy leading to significant lowering of malaria morbidity and mortality.